WORK WITH ME
ONLINE OFFERINGS
SHOP
ABOUT
CONTACT
DONATE
WORK WITH ME
ONLINE OFFERINGS
SHOP
ABOUT
CONTACT
DONATE
HEAL WITHIN NEW CLIENT INFORMATION
NEW CLIENT INTAKE FORM
Fill out information to your best ability
Please Select
New Client
Existing Client
Name
*
First Name
Last Name
Email
*
Phone #
*
(###)
###
####
Date of Birth / Age
Occupation
# Of Children
Relationship Status
Do you have symptoms / complaints in any of the areas listed?
Check all that apply
Neck
Ears
Eyes
Jaw Problems
Back - Upper
Back - Middle
Back - Lower
Heart Conditions / Arrhythmia
Hips
Knees
Ankles
Feet
Hands / Fingers
Nails - Nail Biting
Wrists
Arms
Elbows
Shoulders
Indigestion / Heartburn / Ulcers
Stomach / Digestion Issues
Constipation
Menstrual / Female Area Problems
Menopause Problems
Endometriosis
PCOS
Bladder Problems
Migraines
Headaches
Skin Problems
Blood Pressure - High
Blood Pressure - Low
Thyroid Problems
Insomnia
Fatigue
Arthritis
Rheumatoid Arthritis
Fibromyalgia
Carpal - Tunnel Syndrome
Sciatica
Vertigo / Dizziness
Weight Problems
Diabetes
Sinus Problems
Asthma
Allergies - Outdoors
Allergies - Food
Cancer
Concern #1
Concern #1: When did symptoms begin?
Concern #1: Did any event / accident take place durning that time?
Note: We will discuss this further in our session. Ex. Relationship ended. Loss of family member. Car accident. Injury. Job change. A move. Etc.
Concern #2
Concern #2: When did symptoms begin?
Concern #2: Did any event / accident take place durning that time?
Note: We will discuss this further in our session. Ex. Relationship ended. Loss of family member. Car accident. Injury. Job change. A move. Etc.
Additional Areas Of Concern:
Location / Description / Frequency
Do you have a medical diagnosis? List all conditions:
List any surgeries you have had and estimated year:
Write NA if none
Are you working with any other practitioner for your symptoms?
Medical Doctor
Physical Therapist
Chiropractor
Massage Therapist
Acupuncturist
Naturopathic Doctor
Counselor / Therapist
Other
Can you identify any emotions or feelings that are affecting your daily life?
Check all that apply:
Anger
Irritability
Depression
Grief / Loss
Sadness
Anxiety
Burn Out / Exhausted
Unmotivated
Resentment
Family Stress
Relationship Stress
Work Stress
Fear of Future
Other - Use box below
Provide any additional emotions or feelings you would like to share:
PLEASE NOTE:
In our session we will address 1 concern to begin. A follow-up session may be needed to continue addressing the concern and/or any additional concerns you have listed. We will address your next concern if time allows.
What concern would you like to address in our first session?
If there is time what is the second concern would you like to address in our session ?
Disclaimer
*
I am fully aware and agree that this session is not to diagnose any physical and/or mental condition(s). It is not meant to replace professional medical advice. Any techniques used are not a sole form of treatment for physical and/or medical problems. The intent for this session is to provide information to help in the healing process for your emotional and spiritual wellbeing.
Yes
No
Prior to Session - Introduction Video
You will receive a link to an introduction video (5-7 min) prior to your session. This video will provide valuable information including: About myself and work / Flow of session / Introduction to practices we will use in our session. *If I am unable or do not watch video prior to session I am aware that this information will be addressed at the beginning of our session and the time will be deducted from the session.
I AGREE to watch video prior to session
Prior to Session - Additional Information
Once your intake form is received I may reach out prior to your session via email or phone/text for additional information/clarification to better maximize and prepare for our session together.
Scheduling Your Session
What times and days work best for you? Select ALL that apply I will be in contact via email or text within 24 hours to schedule your session.
Monday - morning
Monday - evening
Tuesday - morning
Tuesday - evening
Wednesday - morning
Wednesday - evening
Thursday - morning
Thursday - evening
Friday - morning
Friday - evening
Saturday - mid morning
Sunday - mid morning
Thank you for filling this intake form out. I look forward to our session together.
Your intake form as been submitted. I look forward to our upcoming session together.
